Effect of Two Educational Models including Face-to-Face and Training Pamphlets for Disease Control in Asthmatic Patients

Background: Asthma is a common condition in which the patient requires self-management and teaching programs that lead to reduced prevalence and mortality. The main aim of this study was to improve the management knowledge of the disease through the use of educational tools, pamphlets and face-to-face lecture, concurrent with evaluating and comparing its effectiveness in response to treatment. Materials and Methods: In this study, 82 asthmatic patients were enrolled. Training necessary to control the disease and use of drugs were provided to patients in one group by pamphlets (39 patients) and the other by face-to-face education (43 patients). After a month, Disease control examination and Asthma Control Test (ACT) scores were evaluated and compared. Results: The mean age of participants was 39.12±14.25 years. There was no significant difference between the two groups in age, gender and education (P> 0.05) and no significant difference in asthma control between the two groups before the intervention (P = 0.065). The overall asthma control score in the pamphlet was increased from 15.43±4.99 at baseline to 20.58±4.47 in the assessment after one month education (P <0.001) and in face-to-face training an overall score was increased from 13.27±5.39 to 21.95±2.77 (P <0.001). After one month education, asthma control score was increased 5.23 ± 6.88 in pamphlets group and 8.9 ± 6.32 in face-to-face group (P = 0.014). Conclusion: Evaluation of both educational methods showed face-to-face training is more efficient.

conditions, exposure to air pollution and poor health statues it seems under diagnosed (6).
Asthma disease affects the living and social activities of patient's life and limits their physical activity that might lead to psychological problems. The results of some studies relating to quality of living in patients with asthma indicate poor quality of life in these patients (7)(8)(9). Management of asthma requires daily self-management associated with acquisition of knowledge and related skills. Self-management is any behavior that people with asthma and their family members should do to reduce the effects of this chronic disease including diet therapy, along with a complex cognitive behavior, self-monitoring and linking between diet therapy and clinical symptoms (10).
Training programs can reduce incidence of the disease, mortality of patients, cost of treatment and improve the quality of life of these patients. In the field of selfmanagement of asthma, considerable research has been done and many of them showed that the main cause of failure in the treatment of asthma is drug disobedience by patients and taking the wrong medication (11,12).
Training can be done face-to-face by the therapist, or indirectly by a variety of educational pamphlets and videos but operating the most efficient and comprehensive method in patients is the key point (13).
Pamphlets are informative published subjects containing training information. Designing and developing educational pamphlet is very simple and low cost and can be widely distributed among them (14).
On the basis of mentioned pamphlets properties and the requirement for such an efficient, long-term educational instrument to teach the asthmatic patients, in this study the effectiveness of correct training of consumption of medicine and controlling environmental stimulation of asthma evaluated by two methods namely face-to-face method by the therapist and education by means of training pamphlets, was evaluated.

Enrollment and sample size
The study began on June 15, 2016 and 82 patients that were older than 12 years, and after obtaining consent, referred to the Clinic of Allergy and Lungs and enrolled.

This study was done in Allergy Research Center and
Clinical Immunology and Allergy Clinic. Demographic data like age, gender, education level, severity of the disease and the state of patients was assessed before and after training. Asthma was confirmed by history, physical examination and spirometry and for allergy confirmation skin prick test was performed as well; at the end participations were randomly divided into two groups.

Inclusion and exclusion criteria
We recruited asthmatic patients which were approved by a physician via spirometry or skin test. And as this clinical trial does not have any intervention, it does not have exclusion criteria and the patients were selected alternately.

Study Design
At first, pamphlets were prepared about asthma and its irritants, how to use various sprays and something about food allergies.
In one group the mentioned pamphlets were given to All questions were evaluated based on the past 4 weeks criteria and each question was assigned a score between 1 and 5 and at the end, the higher the score the better control of the disease.

Statistical analysis
Statistical analysis was performed using SPSS 16 and P value of less than 0.05 was considered statistically significant.

Sample size
The sample size was determined according to the same article by Kotwani et al. with specificity of 95% and sensitivity of 80% (15). The minimum sample size was 40 in each group and since there was the possibility of dropping samples, taking into account 20% drop, the sample size was considered as 50 in each group.

Ethical considerations
The study protocol was approved by the Ethics

RESULTS
In this study 82 asthmatic patients were evaluated and divided in two groups including pamphlet group (39 patients) and face-to-face training (43 patients) group.
The average age of patients participating in this study was 39.12±14.25  years. In the study of each group individually, the average age was 36.87±14.28 years in pamphlet group and in face-to-face training group it was 41.16±14.08 years (P = 0.175) ( Table.1) Gender distribution of patients was not significant between the two groups; in the pamphlet group, 30.8% were male and in the face-to-face group 46.5% were male (P = 0.144). There was no significant difference between the two groups in terms of distribution of education level and age range (P = 0.858 and P = 0.634).
There was no significant difference between the two groups before training in terms of asthma control (P = 0.065) and showed that the two groups were homogeneous in terms of asthma severity.
The total score in the pamphlet group increased from 15.43 ± 4.99 at the beginning of the study to 20.58 ± 4.47 in the evaluation one month later, and in the face-to-face training group the overall score increased from 13.27 ± 5.39 to 21.95 ± 2.77. Differences after the intervention compared to the situation prior to the intervention in both groups were statistically significant (P <0.001) (Figure 1).
Compared before and after one-month training, it was observed that in pamphlets group the score increased about 5.23±6.88 points and in face-to-face training increased at a rate of 8.9±6.32, representing a better improvement in the state of patients in the face-to-face group (P = 0.014). Considering the basis of age in the age categories under 18 and over 50 years, there was no significant difference between the two groups, respectively (P = 0.14 and P = 0.86), but in the age group 18-50 years the state of patients in face-to-face training was significantly better (P = 0.005) ( Table 2). Comparison within the three age categories in any of the two pamphlets (P = 0.153) and face-to-face training groups (P = 0.388) was not statistically different. Intra-group comparison using t-test showed that there was no significant difference between the two levels of education in the two pamphlet and face-to-face groups, respectively (P=0.272 and P=0.559).
We used covariance analysis to evaluate the interferer variables such as gender, sex and ACT before the intervention ( Table 3). The results of covariance analysis showed that by controlling interfering parameters such as gender, age and score, before the intervention, outcome of training in face-to-face group showed approximately 2.069 higher score than pamphlet group.

DISCUSSION
In this study both methods made the significant Our results show that there was no significant difference in the age categories under 18 and over 50 years (respectively P = 0.14 and P = 0.86), but in the age categories 18 to 50 years face-to-face training was better than pamphlets (P = 0.005). In men, there was no significant difference between the two methods of education (P = 0.86), but face-to-face training was more effective in women (P = 0.033). There was no significant difference in the effectiveness of two types of education in patients with elementary and illiterate level (P = 0.396), but faculty members were more effective in face-to-face training (P = 0.015).
We expected that the pamphlets education would be more effective in higher literacy level group than face-toface training, but contrary to expectation, this method in illiterate and primitive group had similar performance in face-to-face higher literacy training group.
It was also expected that the effectiveness of the pamphlet at a young age (18 to 50 years) and female gender would probably be higher for study, but contrary to expectation, face-to-face education was more effective.
However, these results were obtained in single-variable analysis, while using covariance analysis differences between age groups were not significant. One of the reasons for lower efficiency of the pamphlet method in this study may be the incomprehensibility of the pamphlet for the general public training.
As Sarma et al. in a study in Australia reported the availability and understandability of asthma related pamphlets, considering Grade 1 as the most comprehensible to Grade 12 for the hardest; one third of the patients got Grade over 9 and two thirds Grade 8 or higher. These results showed that a small percentage of the pamphlets available for the educational project were legible and understandable (19).
The first limitation of this study was the small sample size and the second limitation was about the asthma control that was evaluated by a measurement tool named ACT questionnaire, which is part of its judgment and scoring based on the patient's own opinion, which can impact the results of the study.

CONCLUSION
In this study the efficiency of both educational pamphlet and face-to-face training in controlling symptoms of asthma patients has been shown. It can be inferred that using such an accessible and simple educational intervention, if properly designed with all necessary and needed information at the patient's level, might be better for the asthma-related knowledge, management and even the attitude towards the disease.
However, on the basis of our results we investigated that the effectiveness of face-to-face training was more than pamphlets, therefore this study is recommended to make use of face-to-face training by therapist and patients; with a greater emphasis on regular visits of patients by doctors.
Although pamphlet is a permanent reminder; it can be read anytime and anywhere and also an auxiliary method for transmitting information to patients, especially for information that requires frequent repetition and practice.